International Council of Ophthalmology

Ophthalmic Education:

Principles and Guidelines of a Curriculum for Ophthalmic Education of Medical Students: Chapter X: Ocular Manifestations of Systemic Diseases

Educational Goal:

Students should understand the signs and symptoms of ocular conditions that are associated with important systemic diseases and diagnoses, such as congenital, traumatic, vascular, neoplastic, autoimmune, idiopathic, infectious, metabolic or endocrine, and pharmacologic or toxic conditions.

A. Congenital.***

(REF. 2F Slide 4-6)

a. Neurofibromatosis.*** (REF. 22 Fig. E08)

B. Trauma

(REF. 2F Slide 7)

a. Shaken baby syndrome.***

C. Vascular causes.*

1. Hypertension.* (REF. 3 Case 5, Hypertensive Retinopathy, p. 10)

a. Posterior segment.* (REF. 2F Slide 8-10)

i. Arteriolar narrowing.* (REF. 2F Slide 9)

(a) Copper wire.*

(b) Silver wire.*

ii. Hemorrhages (flame-shaped).*

(a) Exudates (cotton wool spots, macular star).*

iii. Papilledema (malignant hypertension).* (REF. 2F Slide 10)

2. Intracranial hypertension.* (REF. 2F Slide 11, 12)

3. Embolic Hollenhorst plaque.** (REF. 2F Slide 13-15) (REF. 22 Fig. K47)

4. Amaurosis fugax.** (REF. 2F Slide 16-20)

a. Transitory Ischemia Attack (TIA).* (REF. 2F Slide 13)

i. Visual changes.*

ii. Fundus findings.** (REF. 2F Slide 18)

b. Cerebrovascular accident – stroke.*

i. History.*

ii. Visual field findings.* (REF. 4 Fig. 7.12)

(a) Homonymous hemianopia.*

(b) Homonymous quadrantanopia.*

5. Central retinal vein occlusion.*** (REF. 2F Slide 21) (REF. 22 Fig. K37)

6. Migraine.*** (REF. 2F Slide 22-24)

7. Blood dyscrasias.** (REF. 2F Slide 25-32)

a. Sickle cell anemia.**

i. Anterior segment.**

(a) Importance of recognizing traumatic hyphema as a risk for acute vision loss.*

(b) Anterior segment ischemia.***

ii. Posterior segment.*** (REF. 2F Slide 30-32)

(a) Salmon patch.***

(b) Black sunburst.***

D. Malignancy.**

(REF. 2F Slide 33)

1. Primary.*

a. Intraocular.**

i. Retinoblastoma.* (REF. 22 Fig. H27, H28, H29)

ii. Uveal malignant melanoma.** (REF. 3 Case 7, Malignant Choroidal Melanoma, p. 14) (REF. 22 Fig. K25, K26)

iii. Lymphoma.*** (REF. 2B Slide 65)

b. Eyelid.**

i. Basal cell carcinoma.** (REF. 22 Fig. F02, F03)

ii. Sebaceous carcinoma.**

iii. Melanoma.***

c. Orbit.***

i. Lymphoma.***

ii. Lacrimal gland tumors.*** (REF. 22 Fig. F25, F26, F27, F28, F29)

iii. Other.***

2. Secondary.***

a. Extension from sinus carcinoma.***

b. Metastasis.***

i. Adults-carcinoma.*** (REF. 2F Slide 34-36)

ii. Children-leukemia –Roth Spots.*** (REF. 2F Slide 28)

E. Autoimmune disease.*

(REF. 2F Slide 39-76)

1. Thyroid eye disease (Graves’ ophthalmopathy).* (REF. 3 Case 4, Endocrine Ophthalmopathy, p.8)

a. Clinical (Werner classification of severity of ophthalmopathy).** (REF. 2F Slide 66-71)

b. Treatment for thyroid orbitopathy.**

i. Non-surgical.***

(a) Corticosteroids.***

(b) Radiation.***

ii. Surgical.***

(a) Eyelid.*** (REF. 22 Fig. F52)

(b) Orbital decompression.***

2. Rheumatoid arthritis.** (REF. 2F Slide 46-51)

a. Dry eyes.** (REF. 22 Fig. B05)

b. Episcleritis.** (REF. 2F Slide47) (REF. 22 Fig. B50)

c. Scleritis.** (REF. 2F Slide 48-50)

d. Peripheral corneal ulceration.** (REF. 2F Slide 51) (REF. 22 Fig. B25)

3. Myasthenia gravis.**

a. Ocular motility disturbance – noncomitant.**

b. Lid eye malposition – ptosis.** (REF. 2F Slide 75)

4. Wegener’s granulomatosis.**

a. Orbital involvement.** (REF. 11, Fig. 4-11 a,b,c)

F. Sarcoidosis and other inflammatory diseases.**

(REF. 3 Case 10, Sarcoid uveitis, p 20.)

1. Sarcoidosis.**

a. Clinical findings.**

i. Eyelid nodules.**

ii. Conjunctival nodules.**

b. Uveitis – granulomatous versus nongranulomatous.**

i. Non-granulomatous associated systemic diseases: juvenile rheumatoid arthritis, Reiter’s syndrome, Behçet’s disease.*** (REF. 30)

ii. Granulomatous (associated diseases-sarcoidosis, Tuberculosis, fungal).*** (REF. 2F Slide 78)

c. Choroiditis and retinal vasculitis.** (REF. 2F Slide 79)

d. Diagnostic tests.**

i. Imaging, gallium scan.***

ii. ACE level.**

2. Behçet’s disease.***

a. Clinical triad findings.** (REF. 13 Fig 7-15-17) (REF. 30)

i. Acute iritis with hypopyon.***

ii. Aphthous stomatitis (canker like mouth ulcers).***

iii. Genital ulceration.***

G. Infectious.**

1. AIDS.**

a. Adnexal.**

i. Bacterial infections of the lids and adnexa.** (REF. 19, Fig. 4-10 Fatal orbital cellulitis due to Staphylococcus aureus, p.41)

ii. Kaposi’s sarcoma.* (REF. 19 Fig. 4-2 Extensive Kaposi’s sarcoma of face and eyelids, limiting vision, p.37)

iii. Non-Hodgkin’s lymphoma.*** (REF. 19 Fig. 4-11, Bilateral lid swelling due to orbital lymphoma p. 41)

b. Conjunctiva.***

i. Kaposi’s sarcoma.*** (REF. 19 Fig.4-3 Kaposi’s sarcoma in the inferior cul-de-sac, mimicking subconjunctival hemorrhage, Fig. 4-4)

(a) Multiple Kaposi’s sarcoma lesions on bulbar conjunctiva.***

(b) High power view of one such lesion reveals its vascular nature.***

(c) Squamous cell carcinoma ophthalmology.*** (REF. 19 Fig. 4-6 Squamous cell carcinoma of conjunctiva of superior limbus p.39)

c. Posterior segment.*** (REF. 2F Slide 82)

i. CMV retinitis.* (REF. 2F Slide 84) (REF. 3 Case 25, Cytomegalovirus Retinitis, p.50) (REF. 22 Fig. K29)

ii. Cotton wool patches.* (REF. 2F Slide 83)

2. Syphilis.***

a. Anterior segment.***

i. Interstitial keratitis.***

ii. Anterior uveitis.***

b. Posterior segment.***

i. Neuroretinitis.***

ii. Papillitis.***

iii. Posterior uveitis.***

3. Other systemic infections.*

a. Viral (herpes zoster ophthalmicus “shingles”).* (REF. 4 Fig. 8.13)

b. Fungal (e.g., Candida endophthalmitis).***

c. Bacterial (e.g., TB uveitis).***

d. Toxoplasmosis.*** (REF. 22 Fig. K82, K83, K84, K85)

e. Onchocerciasis.*** (REF. 17, Fig 21 1-2 and 1-3)

H. Diabetes.*

1. Anterior segment.*

a. Corneal wound healing.***

b. Cataract.*

2. Posterior segment

a. Diabetic retinopathy.* (REF. 2A Slide 18, 19, 34)

i. Background retinopathy - hard exudates.* (REF. 22 Fig. K40), hemorrhages, microaneurysms (REF. 2A Slide 19-22, 24) (REF. 3 Case 1, Nonproliferative Diabetic Retinopathy, p. 2) (REF. 22 Fig. K14, K15, K40, K41)

ii. Preproliferative retinopathy - soft exudates, intraretinal microvascular abnormality.*** (REF. 2A Slide 25)

iii. Proliferative retinopathy – neovascularization of the disc (REF. 22 Fig. K41) neovascularization elsewhere (REF. 2A Slide 26, 27) vitreous hemorrhage.** (REF. 22 Fig. K86) (REF. 2A Slide. 28) (REF. 3 Case 9, Proliferative Diabetic Retinopathy, p. 18)

b. Ischemic optic neuropathy.***

Clinical Competencies

Students should:

Recognize retinal exudates and hemorrhages on dilated fundus exam.*
Understand importance of traumatic hyphema in sick cell anemia.***
Recognize retinal arteriolar narrowing (copper wire/silver wire) on dilated fundus exam.*
Detect disc edema on fundus exam with direct ophthalmoscopy.*
Perform neurologic Examination of all cranial nerves.*
Perform confrontational visual fields with recognition of hemianopias.*
Recognize limited ocular motility.*
Recognize proptosis.*
Recognize photophobia as symptom of uveitis.*
Assess for malignant neoplasms of eyelids (carcinoma, melanoma).***

* Basic Level: Necessary in the education of medical students worldwide.

** Standard Level: A higher level of ophthalmic understanding than the basic curriculum of most international medical students.

*** Advanced Level: Advanced cognitive and clinical skills more appropriate for students who seek further training in ophthalmology, which may be covered in an ophthalmology elective in medical school.

(Also see: More on Educational Priorities)

Next: XI. Intraocular Tumors

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